The terms opiate and opioid are often used interchangeably. Opiates are medications derived from opium poppy such as morphine and codeine, while opioids refer to opium-like substances including endogenous substances such as endorphins, as well as exogenous synthetic drugs that interact with opioid receptors. The generic term “Opioid” (including opiates and opioids) is therefore the preferred term for use throughout this report.

In Canada, the prescription of opioids for pain management increased by about 50% between 2000 and 2004. The increase in prescribing of opioids has been associated with increase in misuse, abuse, diversion, and opioid-related overdoses that are accompanied by increasing emergency department visits, hospitalizations, and deaths. In 2008, the prevalence of any use of opioid pain relievers in general population in Canada was 21.6%. In 2011, the rate was decreased to 16.7%. There was an almost 250% increase in the number of emergency visits in Ontario related to narcotics withdrawal, overdose, intoxication, harmful use and other related diagnoses from 2005–2006 to 2010–2011.

Given the current rate of opioid overdose and harms associated with opioid use, stepwise approaches to prescribing, which progress from non-opioids to weak opioids and finally strong opioids such as hyrdomorphone if pain persists, have been proposed. As such, there is a growing need for clinical evidence and guidance for the use of stepwise approaches for the prescription of opioid for non-cancer pain management in the emergency department and in-hospital setting.

Contents

• CONTEXT AND POLICY ISSUES
• RESEARCH QUESTIONS
• KEY FINDINGS
• METHODS
  • Literature search strategy
  • Selection criteria and method
  • Exclusion criteria
  • Critical appraisal of individual studies
• SUMMARY OF EVIDENCE
  • Quantity of research available
  • Summary of study characteristics
  • Summary of critical appraisal
  • Summary of findings
  • Limitations
• CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING
• REFERENCES
• APPENDIX 1 AMSTAR Checklist for the Quality Assessment of Systematic Reviews
• APPENDIX 2 Checklist for the Quality Assessment of Guidelines (AGREE II)
• APPENDIX 3 Selection of Included Studies
• APPENDIX 4 Characteristics of the Systematic Review of Guidelines by Nuckols et al. (2014)
• APPENDIX 5 Summary of Critical Appraisal of Systematic Review by Nuckols et al. (2014) Using AMSTAR
• APPENDIX 6 Summary of Critical Appraisal of ACEP Guidelines Using AGREE II
• APPENDIX 7 Summary of Findings of the Systematic Review of Guidelines by Nuckols et al. (2014)
• APPENDIX 8 Summary of Recommendations of the Guidelines of the American College of Emergency Physicians (ACEP) by Cantrill et al. (2012)
• APPENDIX 9 Grading of Recommendations and Levels of Evidence

Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.